GTHSGTC Application

GTHSGTC Application

Invest in your child’s future with free, hands-on mentorship and exclusive career exploration. Fill out the application below to reserve their spot today!
Applicant Information
Applicant Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Shirt Size
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Parent / Guardian 1
Parent / Guardian 1 Full Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to Applicant
Parent / Guardian 2
Parent/Guardian 2 Full Name

First NameMiddle NameLast Name
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Relationship to Applicant
Emergency Contact and Medical Information
Emergency Contact Name

First NameMiddle NameLast Name
Relationship to Applicant
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Phone Number
Who is the best person to contact in case of an emergency.Format: (000) 000-0000.
Emergency Contact Instructions
Medical Concerns
Medications
Allergies
Explanation for Any Yes Responses
Emergency Procedure Instructions
School Information
Physician Name

First NameMiddle NameLast Name
Physician Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
School Name
Guidance Counselor Name

First NameMiddle NameLast Name
Guidance Counselor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guidance Counselor Email
example@example.com
Year
GPA
Favorite Subject 1
Favorite Subject 2
Least Favorite Subject 1
Least Favorite Subject 2
Attendance Rating
Suspension Status in the Last 2 Years
If yes, please explain suspension status
Plans and Activities
Post-graduate plans

Other
If Other, please explain
Top college/university choice 1
Top college/university choice 2
Intended major
Career aspirations
Do you participate in sports or activities?
Do you participate in volunteer or community service?
Activity 1 name
Activity 1 frequency
Activity 2 name
Activity 2 frequency
Activity 3 name
Activity 3 frequency
Activity 4 name
Activity 4 frequency
Activity 5 name
Activity 5 frequency
Applicant Certification and Signatures
The answers given herein are true and complete to the best of my knowledge. I also authorize the investigation of all information in this application as may be necessary for arriving acceptable into the Got to High School Go to College mentoring program. In the event of acceptance, I understand that false or misleading information given in my application may result in discharge from the program
Applicant Certification Printed Name

First NameMiddle NameLast Name
Type applicant's full name to sign
Applicant Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type parent's full name to sign
Parent/Guardian Date for Application Certification

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Release For Medical Treatment

In the event of an emergency and the inability of the Alpha Phi Lambda Chapter of Alpha Phi Alpha Fraternity, Inc. to obtain my consent, I hereby give permission for Alpha Phi Lambda to authorize any medical treatment or surgery in which a qualifies physician or surgeon shall deem prudent for my child. I shall incur any costs associated with these actions.
Medical Treatment Release Date 1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type parent's full name to sign
I authorize the Alpha Phi Lambda Chapter of Alpha Phi Alpha Fraternity, Inc. to use photos and/or other likenesses of myself, my child, or the child for whom I have legal guardianship and who is participating in the Go to High School Go to College mentoring program for promotional materials regarding youth mentoring. Such likenesses will not be sold to other parties. Promotional materials bearing these likenesses may be distributed for free to the public and posted on the Alpha Phi Lambda Chapters and G.W.C. Brown Legacy Education Fund websites. The Alpha Phi Lambda Chapter and G.W.C. Brown Legacy Education Fund reserve the right to use any photo or likeness for a time period beginning when this form is signed and ending upon written request by participant, parent or legal guardian.
Photo Release Date 1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type parent's full name to sign
Parental Permission Date 1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type parent's full name to sign
Should be Empty:

GTHSGTC Application

Applicant Information

Parent / Guardian 1

Parent / Guardian 2

Emergency Contact and Medical Information

School Information

Plans and Activities

Applicant Certification and Signatures